Provider Demographics
NPI:1013544840
Name:EDMISTON, BREANNA (PA-C)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 BRODHEAD RD STE 12
Mailing Address - Street 2:
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3149
Mailing Address - Country:US
Mailing Address - Phone:724-728-3575
Mailing Address - Fax:
Practice Address - Street 1:3468 BRODHEAD RD STE 12
Practice Address - Street 2:
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-3149
Practice Address - Country:US
Practice Address - Phone:724-728-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059675207X00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery